R3 Advice
Thoughts meant to be helpful for the R3 year by Dr. Gibbons # Be a leader for the juniors. I notice that the R3s tend to shy away from “leading team” and giving directions. I think this is in part b/c the R3s are looking forward to some independence and want this also for the R2s. But early in the year is not the time. R2s need direction on their responsibilities for that day, specific tasks, what patients you are worried about, what cases they will cover, who goes to clinic, when to have patients ready for the OR, how to be on time for cases etc. Don’t shy away from this task. You are setting a role model. Direct the students too. Don’t assume R2s can all manage sick ICU patients – they will need help. # OR cases during the weekday…who does the case. This issue has been a struggle as to who should cover an add-on cases during the weekday (daytime hours) – whether clinic day or OR day. There is no right answer, except to be consistent so there aren’t hard feelings from the R2s. For example, if you are ok with an R2 covering the case, then have a set protocol (usually the call R2 does the case). If we work in an add-on case into the regular OR day – it can be swing R2 who does the case (as it is their OR day), but sometimes, the call R2 will want to do the case, b/c they worked up the patient etc. So one option is to have the swing R2 do the add-ons (assuming they aren’t busy in another OR and that it is a R2 level case), until a certain time…say 3 pm, then on-call R2 should take the case(s) (something like that). # OR cases during the weekday…when to do them. The decision about when to do pink cases during the day (assuming a room opens up) is that of the on-call attending, not the clinic attending. The on-call attending can operate with the on-call R2 or have them cover clinic if a more senior resident is needed. Don’t make the assumption that we can’t do cases during clinics, it is rather that the on-call attending must figure out staffing so the clinic isn’t unduly burdened (or decide that they want the case to go later). # Never “give up” OR time. What I mean by this, is if the OR front desk (Samsong) mentions she has an extra room, we will usually take it. Let one of the attendings know, so they help make the final decision to accept it and figure out how to staff the room. # OR start time. We need to have patients in their OR rooms before 7:30. We continue to struggle time and time again (no pun intended) with this issue b/c the consent isn’t done, name is wrong on the consent, no site marking etc. # Don’t drop pinks without discussing with the on-call attending. This has been happening during the past year, so try to avoid it. If it is the middle of the night and you plan to drop the slip in the morning, that is fine and then tell the attending shortly after they arrive in the morning. If it is a big exploratory laparotomy or major case, then page the attending before you drop the slip. # Call the AOD (anesthesiologist on duty) when you drop a pink. This is somewhat new practice (expectation from anesthesia). Someone (R2 or R3 or I will often do it) needs to page and talk to the AOD to tell them about the patient you are dropping the pink slip for. Ideally, whoever knows their workup and management the best. # Staffing consults. Complex cases – and for most vascular and thoracic cases – need to be discussed with the call attending. I saw patients being mismanaged several times this year b/c attendings weren’t called early on. Even if you have a reasonable treatment plan, it is better to call the attending (in the cases I am thinking about, incorrect treatment plans were in place). There is an odd sentiment that the residents don’t want to bother the attendings, but we need to know about patients who have: escalation in care, possible complication from another service, patients you are worried about. It much better to call. # Patients who don’t follow the anticipated course. This happens more often that we would like, so keep your eyes open to this. This is the SBO patient who we are managing conservatively whose pain worsens at night, pain med requirement goes up, uop goes down, etc. Be watchful when they stray off course. # Consult patients. In general, our service is not good about communicating plans to services that consult us. We need to give them this curtesy and let them know, “we are still following” “we are signing off” etc. # Participate in the take-back case if you were involved in the first operation. Seems obvious, but even if the chief is on vacation, and you want to do the “bigger” case, you need to do the take-back case if you were involved in the first case. Luckily, this doesn’t happen often, but just a reminder if it does. # Let the attending who did the first case know about the take-back case. Several times this year, the attending who did the first case wasn’t informed about the need for the take-back or even told the next day that it occured. You need to call the attending– we want to know and we want to participate in the work-up, treatment and in many cases will do the take-back ourselves. # If you are the senior on the service, you should participate in any take-back cases. These are rare events, but even more reason to be involved. A senior this year let the R2 do a bleeding lap choly take-back and chose to stay home. Even better, if you want to let the R2 participate; ask the attending to let you help too. # For red-line cases, an attending to attending discussion is needed to bump another room. # It is very rare to have a pink case bump a scheduled first start case. I learned this from Bennion early on. Basically, you really don’t save anytime trying to put a pink case first, ahead of a previously scheduled elective case. The time it takes to bring the patient to the preop area, have anesthesia preop them, get the OR ready (as they pull the case carts and prepare the rooms the night before)….is too long. All those things can happen as you are doing your first elective case. There are exceptions, but not often. # Thursday Conferences. Not sure why, but over the past year, the number of cases discussed at conference has grown. Be selective and pick about 4-5 in total, ideally those for the upcoming OR days. Not all pathology results have to be discussed, just the most interesting ones. And, if there is a case that needs to go that day, tell us during conference. Discuss patients you are worried about (slides not needed). # Elective case trap. Sometimes patients are not evaluated carefully in clinic and we need to pick this up before the operating room. Reviewing the upcoming big cases is helpful. You will pick the colostomy takedown that didn’t have BE. Don’t trust that all cases that made it on the schedule have been probably vetted. Instead, be the detective in search of what we should have known and don’t. Know everything you can about the patient before you start the operation. # Best not to “run the list” with the on-call R2 during clinic. I noticed this happening on Monday and b/c clinic was light I didn’t say anything. But in general, this should be left to after clinic (or lunchtime). Our clinics have been busy and we need to focus on those patients (or urgent issues). Many days we don’t have the back hall office and having folks reviewing all the inpatients can tie up a computer in the work area or they tie up the phone etc. (This is probably my pet peeve, so other attending may not mind). # Running the list of patients each day with the attending. I have been thinking more about this and it is probably something we should change. Meaning, the attending on-call should hear about all the patients on the service every day. So maybe that is something I can mention on Thursday. # Trust yourself. You will often know the right thing to do, whether it is that a patient needs an urgent operation, needs to be in the ICU, needs to be intubated, etc.